Tuesday, February 23, 2016

What Your Psychiatrist Should Be Doing....

First, I'm going to send you over to read Pete Earley's blog post for today: Treatment Rather Than Punishment In Horrific Case But What Can We Do in the Future? 

So just to recap, this terribly tragic case is about a mother with schizophrenia who stopped going to treatment, became psychotic, put her three-year-old son on a swing and pushed the swing for 40 hours.  The boy died and the mother was found pushing her dead child in a swing.  The judge determined that she was not criminally responsible, and she is being mandated to treatment and allowed to stay in the community if she abides by the terms of her release.  This is an unusual outcome, usually if your child dies because of negligence or abuse, you go somewhere-- if not a prison then a forensic hospital.

So the question comes up as to whether this child's death could have been prevented, who is to blame, and how do we keep such things from happening in the future?  According to an article in the Washington Post, the mother had been admitted to a psychiatric unit in February of 2015, was discharged to outpatient care and was seen at a clinic in April of 2015.  She was diagnosed with schizophrenia.  She took medications and had stopped them only days before the tragic event in May.  The father had pursued full custody of the boy, but the parents ended up with joint custody.  The patient lived with her mother and son in a hotel. 

So Mr. Earley looks at the question of who is to blame. Is the adult patient's mother responsible? No, he contends, parents are limited in what they can do to help an adult child with a mental illness.  Should the hospital be responsible for making sure everyone goes to outpatient appointments months after discharge? No, that is too much to ask.  Social services? Too under-staffed.  And then I got to this sentence:

If someone is taking psychotropic medicine, the doctor who issued that medication should be obligated to monitor his patient.

What does that mean and how does that play out?  As a psychiatrist, when we hear the word "monitor," we think of assessing the patient to make sure the medication is appropriate, that side effects are being monitored (and hopefully minimized) and that recommended blood-work is being done.  I guess I could ask Pete what he meant by this, but instead I wanted to write a blog post.  It does seems like everyone else gets a pass -- the parents, the hospital, social services (~did they have a role?  Who exactly is social services anyway?).  But the psychiatrist should be obligated to monitor the patient.  No passes here.

So let's talk for a moment about the logistics.  A patient goes to a clinic and sees a psychiatrist and a social worker for therapy.  She stopped taking her medications, but there is nothing here about missing an appointment.  Should the doctor be watching patients swallow the pills?  Some people get sick even when they do everything the doctor says, our treatments help but they aren't perfect.  What if a patient who has been hospitalized doesn't show up at an appointment?  Actually, in community clinics, approximately 30% of appointments are not kept and it's possible that the doctor could be scheduled to see 12-25 patients each day.  He or she may call a patient who doesn't show up, but probably not-- it happens numerous times a day.  If a patient does not call to reschedule, eventually, the chart gets tagged, and the therapist calls or writes a letter to the patient saying that if he does not come in by a certain date, his case will be closed.  There is not a mechanism in our system for aggressive pursuit of patients. In fact, many clinics discharge patients if they miss 3 appointments in a row.  In outpatient settings, people are free to say they've decided they don't want treatment, they've decided to go elsewhere, they'll call when they want to come in. Just because someone has had an episode of mental illness-- one that required hospitalization-- it does not mean that we have a mechanism to insist they continue in treatment if they aren't in the criminal justice system --which this woman now is. 

What about Outpatient Commitment, or AOT as some call it -- would that have saved this child?  Well, we don't have it in Maryland, but even if we did, this parent was not repeatedly hospitalized, and she had voluntarily gone to care at the clinic the month before.  Even if we had laws for this, she would not have qualified.  And outpatient commitment is not a guarantee of safety: patients may disregard the orders, or get sick between appointments.

What about a system which includes very easy access to care and outreach service for all patients who have had an episode of illness severe enough to require hospitalization?  Maybe that would have helped, and if you agree, please do send your dollars to fund it because the expense would be astronomical. No where has this.

I don't know the details of this case and the press often reports selectively, so I don't even want to venture a guess as to what may or may not have prevented this tragedy.  I do think that there are some tragedies that we simply have no way of predicting.    


therapyfirst said...

I read this post yesterday, and wanted to reply when I was done, but waited 24 hrs and am now ready to reply. What a turd conclusion, aren't you as a professional just tired of the pervasive scapegoating by those who want to make psychiatry the whipping post for all who fail in America when it comes to mental health struggles?

It's this pervasive silence and rationalizing by so many colleagues that just makes me wonder why I should even bother to renew my board certification in two years. Why, why should I make the effort to stay in this profession when so many just look away or passively nod when others make insincere and demeaning assumptions about psychiatry?

If even half of those who practice active clinical care in the profession would just stand down and not treat people for a couple of weeks, outside of acute care/urgent care needs, watch the country freak out realizing all these allied professions and faux mental health equivalents without the psychiatry training are running full force out of the rooms when the proverbial excrement is hitting the fans with patients suffering real mental illness struggles can't be managed by these charlatans.

Coming to your Maryland private practices sooner than later, note that your Delaware colleagues have been basically blackmailed into having to take Medical Assistance patients in most private practices across the state for the past 15 or more years, and I know this from personal experience having practiced there in the past. Yeah, I bet all these colleagues who read here who practice in Maryland will just jump for joy when that ruling comes down from those control freaks in Annapolis.

Hey, Google "Mike Miller and complaining about legislative voting being posted & 2016" and see how genuine and concerned these career jerks are about honest representation going on in this state. WHEN these legislative slime then find more scapegoating opportunities to dump on psychiatrists here, will some of you finally rise and say those magical words "I'm mad as hell and won't take it anymore"???

Oops, too late...

tracy said...

Therapy First Something makes me think you would understand me and my comments on the interview with the director of "Touched With Fire" and the movie.

Also, this horrifying, tragic incident breaks my heart. All my best Therapy First, wish I could find you!

PseudoKristen said...

What could have been done? I think the people who knew her could have (and should have) reported her to CPS out of concern that she was unstable and that her child was at risk. Then, hopefully CPS would have removed the child. There is no indication that CPS was ever notified before this happened and the hospitalization alone should have triggered CPS being involved. I am all for patients' rights but people shouldn't be able to endanger and kill their children. My aunt who has schizophrenia completely wrecked her child's life. My parents reported her to CPS and Adult Protective Services and she still got to keep her son even though she had trouble taking care of herself. The child would have been much better off if he had been taken away and adopted. He is now an adult and he's a mess. It's sad that he had such a crappy childhood. Children should have the right to grow up in a stable, safe environment.

Joel Hassman, MD said...

Sorry I did not catch the thread went by "therapyfirst", this is Joel Hassman MD so hope this comment is marked accurately.


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Captain Horatio said...

CPS is a joke. Unless the child is in emmenent danger and that danger can be proved, they will not intervene. It does not matter that mom is severely ill, pretendS the kids are sick with various a ailments and has them hospitalized for extended periods of time. It doesn't matter that allows her kids to not go to school or do drugs with a boyfriend. It doesn't matter that mom takes daughter with her when she is hooking up with men. It doesn't matter that step-father is an abusive alcoholic. None of that matters because the kids need their "mother" more. She has had her kids removed twice and Nebraska Family Collaborative gives a little counseling, gives the kids back and things go to the way they were before.